[Wound management with vacuum therapy]

Vacuum assisted wound closure (VAC) is a closed system, which applies negative pressure to the wound tissues. Basic studies have shown beneficial effects on wound blood flow and proliferation of healing granulation tissue. Theoretically, the method acts by removal of excess tissue fluid from the extravascular space, which lowers capillary after-load and thereby promotes the microcirculation during the early stages of inflammation. Additionally, the mechanical effect of the vacuum on the tissue at the wound surface appears to have an "Ilizarovian" effect resulting in an exuberant proliferation of healing granulation tissue. This technique has been used in over 2560 patients at the author's institution over the past 10 years for an expanding list of wound applications in several surgical disciplines. Commonly used orthopedic indications include traumatic wounds following débridement, infection (following débridement), fasciotomy wounds for compartment syndrome, and as a dressing for anchoring an applied split thickness skin graft. The author's personal experience consists of 269 patients treated and has not been associated with any major complications. A low incidence (2.5%) of localized superficial skin irritation occurred when a portion of the vacuum sponge overlapped the affected area. This problem is avoided by carefully confining the sponge to the wound tissue and avoiding the overlap of normal skin. The technique is contraindicated in patients with an allergy to any of the components which contact the skin such as the polyurethane sponge, the adhesive, or the plastic film applied to seal the system to the skin around the wound. Patients whose skin is thin and easily damaged will not tolerate the pulling off of the adhesive film, which is done at the time of sponge removal/change. Also, patients who are fully anticoagulated or patients with large wound surface areas (e.g., burns) may need careful monitoring of electrolytes, hematocrit, and/or fluid balance in an intensive care or burn unit setting. The mainstay of wound care is débridement, and vacuum assisted wound closure is not a substitute for this. It is a novel and welcome addition to the methods available to surgeons charged with the management of challenging wounds, and its final role in the overall list of adjunctive wound treatment modalities is still seeking a final definition.